Form Dhhs 4097 - Individual Contact Form - N.c. Department Of Health And Human Services

ADVERTISEMENT

N.C. Department of Health and Human Services
Division of Public Health
Epidemiology Section • TB Control Program
Individual Contact Form
Contact Information
Tests & Exposure
Treatment
Name:
TST # 1 Date placed: ________________
Treatment plan:
Manufacturer: _______________________
___ INH ___ RIF
Lot #: ______________________________
___ Other _____________________
DOB:
Age:
Site: ______________________________
___ window period prophylaxis
Race:
Gender:
Placed by: __________________________
Declined treatment: ___ yes ___ no
Address:
Read by: ___________________________
Date: ______________________________
Date
started: _________________________
mm reading: ________________________
IGRA date: ________ result: ____________
Date
completed: ______________________
TST # 2 Date placed: ________________
Manufacturer: _______________________
County of Residence:
If treatment not completed, why not:
Lot #: ______________________________
___ TB disease developed
Site: ______________________________
Country of Birth:
___ adverse reaction
Placed by: __________________________
If not U.S., date of entry:
___ died
Read by: ___________________________
___ patient stopped
Date: ______________________________
___ lost to follow-up
mm reading: ________________________
___ provider decision
IGRA date: ________ result: ____________
___ moved
Previous history of TB: ___ yes ___ no
TST # 3 Date placed: ________________
If yes, date: __________________________
Manufacturer: _______________________
Previous history of LTBI: ___ yes ___ no
Lot #: ______________________________
Date of TST/IGRA _______________________________
Site: ______________________________
Placed by: __________________________
___ Positive ___ Negative ________ mm
Read by: ___________________________
Was treatment complete: ___ yes ___ no
Date: ______________________________
Symptom screening done: ___ yes ___ no
mm reading: ________________________
IGRA date: ________ result: ____________
HIV:
___ negative ___ positive ___ declined
Date of HIV test:
Date of symptom screening: _________________________
Date of CXR: ________________________
CXR resutls:
Symptoms/Signs
Exposure site name:
___ Productive cough (>3 wks)
___ Hemoptysis
___ Fever/night sweats
Hours of exposure:
___ Appetite loss
___ Unexplained fatigue
Date identifi ed as a
___ Shortness of breath
contact: ____________________________
___ Chest pain
Priority level:
___ Unexplained weight loss
___ High ___ Medium ___ Low
Comments:
Source case NCEDSS#: ____________________________
DHHS 4097 (Revised 03/14)
TB Control (Review 03/17)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go